Provider Demographics
NPI:1619539905
Name:HENRY, CATHY A (LICSW)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:A
Last Name:HENRY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CATHY
Other - Middle Name:A
Other - Last Name:MUMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-4799
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-345-5562
Practice Address - Street 1:8670 210TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7000
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN151261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1619539905Medicaid